Two mistakes in 2 weeks

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Hello! I am a relitivley new nurse. I graduated college in May of 2017 and started working in July of 2017. This month makes it 11 months since I started working in the emergecney room, and within two weeks Iv made two different major mistakes and need advice.

Last week I mislabeled blood specimen tubes. I put the wrong patient labels on the tubes of blood and sent them tp the lab. The mistake was caught by the laboratory and new blood was draw and correctly labeled and no harm was done to any patients. As soon as I realized the mistake and was notified by lab, I notified the charge nurse who then had to notify the manager the next morning. As a result I was counciled on my mistake and was written up without being suspended. I have reflected on the situation and what happened to cause the incident and aim for this to NEVER happen again.

Now last night I made ANOTHER mistake... I was pulling medication out of the omnicell refrigerator, which is locked unless accessed. As soon as the door opens it prompts you to count the Ativan vials in the container and then enter it into the screen to make sure it is correct before removing any other mediation. I miscounted the Ativan the first time. I took a moment to look at the Ativan again, and then I recounted the vials to equal 10 vials and not 9.

At this point, I step over to the omnicell computer screen to re-enter the correct amount. Which you must do or it will cause a discrepancy. Next I mistakenly set the container with the vials of Ativan, ON TOP OF the fridge INSTEAD OF IN IT! I then go hang my medication and go upstairs with a patient for 15minutes. When I return our charge nurse is asking who left out the Ativan. I pull her to the side and tell her it must of been me. Even though no Ativan was missing from the container, she had to notify management again and now I'm being called into a meeting with the director and the assistant director.

Up until last week I thought I was doing really well. I am very aware that it is human to make errors. But these are two erros that I'm extremely upset even happened! Espically since they were two big ones within a week. What makes it worse about the Ativan incident is that we were not even busy in the emergency room! Has somthing like this ever happened to anyone else? I'm really bummed out and need some advice.

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Aw, it'll be okay. I bet your internal alarms started going off when you initially miscounted the ativan, being on edge a little bit from the mistake the previous week. You focused on getting that count right. This one's an easy fix as far as not having it happen again.

I hate to see this. Don't go in there and crucify yourself.

We can't be sloppy or careless; just the same, this second offense especially is something that even a few years ago we would've said, "oops" and put it back in the fridge and that would've been the end of it. I am against reporting of this very sort of thing.

Just refocus toward being very mindful when performing these kinds of tasks. Try to move on so that anxiety doesn't distract you.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.

Hi,

I am just wondering if you are under significant stress at home or are you having personal issues, as that can make it very difficult to concentrate.

I will say these are two VERY serious errors, given that if the lab ran that blood it would have obviously been resulted on the wrong patient which could have lead to treatment the patient did not need and the other patient not getting any treatment. Leaving Ativan on top of the refrigerator is also very negligent, as someone could have easily taken a vial or two if they wanted to divert it, and it would have been on you since you took it out last. To be honest they may assume you may have been trying to divert. I would expect a possible drug test in your future.

I would guess you will have major consequences for both of these errors. I would seriously look at whatever is distracting you and why you are being careless. I know we are human, but we are also caring for humans, thus paying attention to detail could safe a life.

In your meeting don't make excuse, own your mistakes and tell them how you plan on not letting it happen again. As I said there may be some other consequences, such as additional education, suspension, etc. I do hope you can learn from this and move on, no matter what happens. It is possible that the fast pace of the ER isn't for you.

Annie

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Specializes in school nurse.

Your post has lots of typos/errors. I point this out to ask if perhaps you have difficulty focusing on details. Also, do you recheck things (that should be rechecked)?

Maybe you could come up with a work plan/strategy that would help you increase your attention to task detail as well as build in a "double check"...

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I think it's ridiculous that sitting the ativan on top of the fridge is a "grievous" error, because other nurses or staff can't stop themselves from stealing drugs to sell or shoot up with. But this is the world we live in now...sigh.

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Specializes in LTC, Rural, OB.

I think as long as you own up to your mistakes and verbalize what you have learned from them and will do differently in the future, then everything should be okay. We all make mistakes, it's learning from them and making sure we don't make the same mistake that is important. We have at least one nurse who makes mistakes on a weekly basis (I'm seriously not exaggerating, one day there were three incident reports against her alone) and somehow she finds someone else to blame. Of course, I don't know what happens when she meets with our manager but she continues to make pretty hefty mistakes and doesn't appear to learn anything. How she is still working here, none of us knows. So go into your meeting fully aware of what happened and what you will do to change things from here on out.

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Oh my god.. why do nurses have to report every single thing to management about each other? We are in a hard enough job as it is.. and if no patient was harmed and all ativan is there, you guys could have counted it and placed it back in the fridge together.. the end!! Why must nursing make mountains out of tiny ant hills? ..This is why people leave/burn out

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Oh my god.. why do nurses have to report every single thing to management about each other? We are in a hard enough job as it is.. and if no patient was harmed and all ativan is there, you guys could have counted it and placed it back in the fridge together.. the end!! Why must nursing make mountains out of tiny ant hills? ..This is why people leave/burn out

I actually agree with this. If the nurse (?) that found the Ativans knew who left it up there ( in this case , I don't know ), they could pull him or her aside and say something , count it and replace it in the locked fridge. Both of you say " whew!!" And maybe a mini- teachable -moment from the established employee to this newer employee.

The mislabeled blood , idk. It happens and the lab luckily ( somehow ) caught this. My husband works in the lab at two hospitals and he says " nurses mess up allll the time !" I always get mad at him

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Oh my god.. why do nurses have to report every single thing to management about each other? We are in a hard enough job as it is.. and if no patient was harmed and all ativan is there, you guys could have counted it and placed it back in the fridge together.. the end!! Why must nursing make mountains out of tiny ant hills? ..This is why people leave/burn out

THIS. I mean, good grief. All the Ativan was there and this should have been used as a teaching moment, which are far more effective than write ups. We have to give each some grace, especially our new grad RNs who are under more stress just because they are still in the initial learning phase. Seems so silly to me.

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Specializes in Med/Surge, Psych, LTC, Home Health.

I guess, on one hand you could say that harsher punishment for a new

nurse helps their learning process. "I understand now that leaving Ativan

sitting out is a serious mistake that could have resulted in the medicine

getting stolen".. as a result of getting written up or even suspended

for doing so.

On the other hand, you could say that punishing someone for such a

mistake is unnecessary and only causes more stress and hatred for

the profession.

I lean towards, anyone old or new could make the two mistakes that

the OP made. There are far worse things that could happen.

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